Abstract

The research aimed to study the situations that condition access and quality of health care to lesbians, gays, bisexuals, transvestites and transsexuals (LGBTT) in health services from an integrative review of national and international literature, whose sample of 41 papers was selected in PubMed, Lilacs and SciELO databases from 2007 to 2018. Access and health issues of LGBTT people were discussed in three dimensions: relational, concerning intersubjective relationships among users and professionals; organizational, concerning the organization of services and work processes; and contextual, which covers the effect of vulnerable situations enmeshed with social determinants on the conditions of satisfaction of health needs. The related data showed that LGBTT populations are the target of prejudice, violence, and discrimination, which, added to different social indicators, engender a context of vulnerabilities in access and healthcare. It is necessary to transform health institutions’ practices and social relationships. Otherwise, there is a risk of increasingly warding off those populations from health services.

In this context, inequalities in access and low quality of health care are issues pointed out in different health systems around the world, and primarily affect minority groups, such as lesbian, gay, bisexual, transvestite and transsexual (LGBTT) populations44 Albuquerque GA, Garcia CL, Quirino GS, Alves MJA, Belém JM, Figueiredo FWS, Paiva LS, Nascimento VB, Maciel ES, Valenti VE, Abreu LC, Adami F. Access to health services by lesbian, gay, bisexual, and transgender persons: systematic literature review. BMC Int Health Hum Rights 2016;16(2):1-10.,55 Meads C, Carmona C, Kelly MP. Lesbian, gay and bisexual people's health in the UK: a theoretical critique and systematic review. Diversity and Equality in Health and Care 2012; 9(6):19-32.. The social imaginary that institutes binary sexual patterns and promotes the alignments “woman-vagina-maternity-procreation-heterosexuality” and “man-penis-rationality-paternity-heterosexuality”66 Bento B. A reinvenção do corpo: sexualidade e gênero na experiência transexual. Rio de Janeiro: Garamond; 2006. builds a non-place or a displaced place for those who fail to meet the standards. So, where and how would they be taken care of in their different health needs? In the closet?

The closet metaphor enacts how health services have been the scene of denials and concealments of the sociability of LGBTT populations. However, in this discussion, it is highlighted that the scientific literature on this topic has hardly had any visibility, thus the importance of underlining it as a large, expanded closet. Bringing this debate out of the closet is also promoting reflections, incursions, and criticisms in the field of knowledge.

The world of dissent from the heterosexual norm is very vast. Letters L, G, B, T, and T perceived only as an acronym can lead to the illusion of homogeneity. Each of these letters carries within itself an extensive and diverse set of experiences, as per situations and intersectional markers. However, the experiences of these communities are traversed by some common force lines, subjected to stigmas, prejudice, and violence that are also expressed in access and health care44 Albuquerque GA, Garcia CL, Quirino GS, Alves MJA, Belém JM, Figueiredo FWS, Paiva LS, Nascimento VB, Maciel ES, Valenti VE, Abreu LC, Adami F. Access to health services by lesbian, gay, bisexual, and transgender persons: systematic literature review. BMC Int Health Hum Rights 2016;16(2):1-10.

5 Meads C, Carmona C, Kelly MP. Lesbian, gay and bisexual people's health in the UK: a theoretical critique and systematic review. Diversity and Equality in Health and Care 2012; 9(6):19-32.-66 Bento B. A reinvenção do corpo: sexualidade e gênero na experiência transexual. Rio de Janeiro: Garamond; 2006.. All of this pointed to a long path of political disputes, conflicts, and negotiations in the field of fundamental rights and citizenship77 Castoriadis C. A instituição imaginária da sociedade. Rio de Janeiro: Paz e Terra; 1982.. In modern times, laws, norms, policies, protocols, among others, are relevant instruments in the enactment of these rights88 Bobbio N. A era dos direitos. Rio de Janeiro: Campus; 2004..

This paper, through an integrative review of national and international literature, discusses conditionants and challenges to accessing and quality of health care for lesbians, gays, bisexuals, transvestites, and transsexuals in health services.

Methodological route

This is an integrative review of national and international literature, a research method that aims to gather, synthesize and critically evaluate results from previous studies on a given topic/issue, allowing the construction of an overview of the current state of knowledge and the identification of gaps and directions for future research99 Mendes KDS, Silveira RCCP, Galvão CM. Revisão integrativa: método de pesquisa para a incorporação de evidências na saúde e na enfermagem. Texto contexto - enferm 2008; 17(4):758-764.. The issue to be discussed in this study is situations that condition access and quality of health care for lesbians, gays, bisexuals, transvestites, and transsexuals in health services.

The survey of scientific publications was conducted in January 2019 in the following databases: U.S. National Library of Medicine (PubMed), Latin American and Caribbean Literature in Health Sciences (Lilacs), and Scientific Electronic Library Online (SciELO). Health Sciences Descriptors (DeCS) were used in both Portuguese and English, combined by the Boolean operator “and”. In the PubMed advanced search, descriptor “sexual and gender minorities” was combined with “access to health services”, “health care” and “quality of health care”, separately. The same combinations were performed in Lilacs and SciELO, resulting in a small number of papers. We also used the terms “homosexuality”, “transsexuality” and “transgender people”, in isolation, to broaden the search on these two databases, and new papers were compiled.

The following inclusion criteria were defined: original papers, available in full in electronic format, in Portuguese, English or Spanish, and published from January 2007 to December 2018. Exclusion criteria were: editorials, letters to the editor, dissertations and theses, papers with an exclusively clinical-epidemiological focus, review papers, essays, and experience reports. The Yogyakarta Principles1010 Corrêa SO, Muntarbhorn V, organizadores. Princípios de Yogyakarta: princípios sobre a aplicação da legislação internacional de direitos humanos em relação à orientação sexual e identidade de gênero. Rio de Janeiro: Observatório de Sexualidade e Política: 2006. were launched in late 2006. They are a fundamental document for the fight against prejudice and discrimination against LGBTT populations in the world. Thus, the starting date considered in this search was 2007.

The first survey returned 3,428 papers. After reading the titles or abstracts, 448 studies were eliminated as they were duplicates, and 2,916 due to the exclusion criteria. As a result, 64 publications were left out for full-text reading. Of these, 23 were excluded because they did not discuss issues related to access or the quality of health care for LGBTT populations. In the end, 41 papers were included in the study and identified by an alphanumeric code. We present the search strategies schematically by the specificity of each database in Figure 1.

Figure 1Flow of the article selection process for the integrative review.

A more descriptive analysis of the material found was carried out after some reading sessions. Some of this information was synthesized in a synoptic table (Chart 1) containing the following items: code accompanied by the reference number, title, first author, journal, and year. Then, we conducted a content analysis guided by the discussion of the integrative review, where the categories access and health care of LGBTT populations were discussed in three dimensions: relational, which concerns the intersubjective relationships between users and professionals; organizational, which refers to ways of organizing services and work processes; and contextual, which encompasses how situations of vulnerability interwoven with social determinants affect the conditions for satisfying health needs.

Results and discussion

What did we find in the closets?

The issue of access and quality of health care for LGBTT populations has been the subject of growing interest in national and international literature. From 2009 to 2014, five publications on the theme were identified, and 36 were found from 2015 to 2018. Regarding the language, 21 papers were in English, seventeen in Portuguese, and three in Spanish. About half of the works found were from PubMed and the rest from Lilacs and SciELO. The studies were developed in Brazil (16), United States (7), South Africa (5), Canada (4), New Zealand (2), Argentina (2), Portugal (1), Sweden (1), Colombia (1), India (1) and Germany (1).

The 41 works were published in 30 journals, sixteen of which were from the U.S., ten Brazilian, two Colombian, one Argentine and one Portuguese. Among Brazilian journals, Ciência & Saúde Coletiva had a higher frequency of papers (4), followed by Physis (2), Interface (2), Cadernos de Saúde Pública (2), Tempus Actas (2), and the remaining ones appeared with a single publication. In Brazil, this scientific production has found space in indexed journals of national circulation that stand out in the dissemination of social sciences and humanities in health studies. Almost all national publications were from journals rated A2, B1 or B2, in the area of collective health by the periodical evaluation system of the Coordination for the Improvement of Higher Education Personnel (Qualis/CAPES). Most foreign journals were rated A1, A2, and B2 for the same area of knowledge.

The professional background of the first authors of the papers was, mainly, in Psychology (12), Nursing (10), and Medicine (9). Four papers had a single author, and a large contingent of three or more authors, expressing strong interaction between different research centers and interdisciplinary dialogues.

Twenty-nine papers used a qualitative approach, nine were quantitative, and three were quantitative-qualitative studies. Previous reviews44 Albuquerque GA, Garcia CL, Quirino GS, Alves MJA, Belém JM, Figueiredo FWS, Paiva LS, Nascimento VB, Maciel ES, Valenti VE, Abreu LC, Adami F. Access to health services by lesbian, gay, bisexual, and transgender persons: systematic literature review. BMC Int Health Hum Rights 2016;16(2):1-10.,55 Meads C, Carmona C, Kelly MP. Lesbian, gay and bisexual people's health in the UK: a theoretical critique and systematic review. Diversity and Equality in Health and Care 2012; 9(6):19-32. also pointed out the predominant qualitative approach in studies on LGBTT health, perhaps because they are more conducive to understanding complex issues, such as gender, sexuality, production of subjectivity and human rights relationships in the area of health. Many used techniques of content analysis or analyses based on hermeneutic-dialectic assumptions in the interpretative process. In quantitative publications, descriptive studies with sociodemographic and clinical information from LGBTT populations prevailed.

As for the participants, the surveys include both LGBTT groups and health professionals, especially doctors. Most of the studies use the recruitment of LGBTT participants through convenience sampling, using the Snowball technique. Noteworthy is the incorporation of participants through online recruitment or with the support of crucial informants from LGBTT social movements. The main advantage of methods that use chains of reference is that, in complex, difficult access social networks, such as LGBTT populations, it is easier for a group member to know another member than researchers to identify them.

Nineteen papers discuss LGBTT populations as a single group, considering the nuances in their analysis. Twelve studies use only the categories transvestite, transsexual, or transgender man/woman or trans people. They discuss the biomedical conditions arising from the process of body transformation, such as the use of hormones, plastic surgery, silicone applications, and even sexual reassignment.

Nevertheless, these analyses transcend the hegemonic and pathological perspective, and the authors seek to unveil the challenges for health promotion, legal assurance of these processes, the strengthening of rights, recognition, and autonomy of these subjects in health services. Eight papers address the quality of health care for lesbians and bisexual women in public and private services. Exclusive gay men studies were found only in two publications, one national and the other international. No paper analyzed only the bisexual condition.

The theme has been concealed in the different studies, suggesting that bisexuality holds a vulnerable place socially, politically and scientifically, and is still perceived as “questionable” sexuality, which hinders the possibility of real inclusion of these subjects. A review of papers published in the United Kingdom also noticed the limited production concerning bisexuals55 Meads C, Carmona C, Kelly MP. Lesbian, gay and bisexual people's health in the UK: a theoretical critique and systematic review. Diversity and Equality in Health and Care 2012; 9(6):19-32.. Despite the importance of the topic, issues related to the health needs of adolescent and young LGBTT were discussed in only three papers. In some studies (5), the researchers – gays, lesbians, and a trans man – explained, in the paper, their sexual orientation or gender identity.

Are the rights recognized to LGBTT populations on the shelves of closets?

Human rights are born as universal natural rights. They develop as positive private rights, to finally find their full fulfillment as universal positive rights88 Bobbio N. A era dos direitos. Rio de Janeiro: Campus; 2004.. In the revised papers, reflections on LGBTT rights claim legitimacy in a set of normative documents, from the 1948 Universal Declaration of Human Rights to the 1994 International Conference on Population and Development in Cairo. The 2007 Yogyakarta Principles – a document that synthesizes a set of principles for the application of international human rights legislation concerning sexual orientation and gender identity – were fundamental to guide States in adopting measures to protect LGBTT populations. The analyses on access conditions and the quality of health care, in most cases, were included in these milestones1111 Müller A. Health for All? Sexual Orientation, Gender Identity, and the Implementation of the Right to Access to Health Care in South Africa. Health Hum Rights 2016; 18(2):195-208.

14 Pinto N, Moleiro C. As experiências dos cuidados de saúde de pessoas transexuais em Portugal: perspectivas de profissionais de saúde e utentes. Psicologia 2012; 26(1):129-151.-1515 Santos AB, Shimizu HE, Merchan-Hamann E. Processo de formação das representações sociais sobre transexualidade dos profissionais de saúde: possíveis caminhos para superação do preconceito. Cien Saude Colet 2014; 19(11):4545-4554. mentioned the role of international normative frameworks when, in the mid-1970s, bodies such as the American Psychiatric Association and the American Psychological Association stopped classifying homosexuality as a disease and, in 1990, the World Health Organization followed the same path, removing it from the list of mental illnesses.

The approval of laws that prohibit crimes against sexual orientation and gender identity – such as U.S. Matthew Shepard Law and the law regulating LGBT marriage in Canada – are taken as examples of legal initiatives that enhance the enforcement of rights1313 Giblon R, Bauer GR. Health care availability, quality, and unmet need: a comparison of transgender and cisgender residents of Ontario, Canada. BMC Health Serv Res 2017; 17(1):283-292.,1616 Martos AJ, Wilson PA, Gordon AR, Lightfoot M, Meyer IH. "Like finding a unicorn": Healthcare preferences among lesbian, gay, and bisexual people in the United States. Soc Sci Med 2018; 209(7):126-133.,1717 Rossman K, Salamanca P, Macapagal K. A Qualitative Study Examining Young Adults' Experiences of Disclosure and Nondisclosure of LGBTQ Identity to Health Care Providers. J Homosex 2017; 64(10):1390-1410.. The papers discuss the case of South Africa, which, despite being surrounded by countries averse to LGBTT rights, opened space for the consolidation of one of the most “progressive” laws in the world; its Constitution was the first to prohibit sexual, and gender discrimination and, currently also protects LGBTT refugees, which is why it concentrates a large number of “sexual asylum seekers” of the continent1111 Müller A. Health for All? Sexual Orientation, Gender Identity, and the Implementation of the Right to Access to Health Care in South Africa. Health Hum Rights 2016; 18(2):195-208.,1818 Cele NH, Sibiya MN, Sokhela DG. Experiences of homosexual patients' access to primary health care services in Umlazi, KwaZulu-Natal. Curationis 2015; 38(2):1522-1530.,1919 Müller A, Spencer S, Meer T, Daskilewicz K. The no-go zone: a qualitative study of access to sexual and reproductive health services for sexual and gender minority adolescents in Southern Africa. Reprod Health 2018; 15(1):12-21.. In Portugal, the Gender Identity Law allows and assists body changes and modification of civil records since 2011, and is a reference for discussing LGBTT rights1414 Pinto N, Moleiro C. As experiências dos cuidados de saúde de pessoas transexuais em Portugal: perspectivas de profissionais de saúde e utentes. Psicologia 2012; 26(1):129-151..

If national and international literature shows how normative and legal instruments are essential for the guarantee of LGBTT rights, it also reveals that they are not sufficient for changes. For its actual effectiveness, other pacts that are not normative and legal and traverse circuits other than those macro-political and macro-institutional must be established. The political struggles that cross the authorities that design, implement and manage public policies are translated and re-enacted in the health services, in the corridors of the units, within offices, in meetings, and in the sociabilities that are woven there daily.

Dismantling the closets of access and quality of LGBTT health care

In this topic, we analyze the discussions in the literature on the conditions that influence access and quality of health care for LGBTT populations. A vast national and international theoretical production has invested in categories and models of analysis for the study of access and quality in health, under varied perspectives, ranging from normative evaluative to more sociological studies. Without intending to delve into more technical issues in the area of health assessment, in this review, the themes and discussions found in the papers were organized into three main dimensions: relational, which concerns inter-subjective relationships between users and health professionals; organizational, which refers to strategies for organizing services and work processes; and, finally, contextual, which shows how different issues of vulnerability affect health situations. The distinction between these dimensions is merely to operationalize the analysis; in publications – as well as in real-life interaction flows – they are complex and interwoven.

The organizational dimension

How the services are organized, the work processes and the effects concerning access and quality of health care for LGBTT populations have been debated in the literature. The inadequate reception was evidenced in several situations, such as the non-recognition of the social name in the medical records and the communications at the counters, in the waiting rooms and the offices, reported by Brazilian transvestites3737 Ferreira BO, Nascimento EF, Pedrosa JIS, Monte LMI. Vivências de travestis no acesso ao SUS. Physis 2017; 27(4):1023-1038.

The meanings assigned to the needs and health care of LGBTT populations are immersed in a continuous network of confrontations, negotiations, legitimations, and transformations, which can bring these subjects closer to or move them away from services, and that is why a broader and permanent discussion on the training devices and in-service education processes is necessary.

The contextual dimension

In a series of studies, situations of vulnerability and social determinants that affect the conditions of satisfaction of the health needs of LGBTT populations are discussed. The ideas of vulnerability and social determination in health refer to the intertwining of material, psychological, cultural, moral, legal and political conditions that strip rights, autonomy, recognition, and participation from people in varying degrees, exposing them to situations of illness and exclude them from the resources available to health4141 Taquette SR, Rodrigues AO. Experiências homossexuais de adolescentes: considerações para o atendimento em saúde. Interface (Botucatu) 2015; 19(55):1181-1191.

42 Lindroth M. Competent persons who can treat you with competence, as simple as that - an interview study with transgender people on their experiences of meeting health care professionals. J Clin Nurs 2016; 25(1):3511-3521.

A study with the LGBTT populations of New Jersey showed that, among the difficulties of access to health services, is the cost of private insurance2121 Qureshi RI, Zha P, Kim S, Hindin P, Naqvi Z, Holly C, Dubbs W, Ritch W. Health care needs and care utilization among lesbian, gay, bisexual, and transgender populations in New Jersey. J Homosex 2018; 65(2):167-180.. In the Brazilian and South African realities, LGBTT populations in situations of poverty face weaknesses in accessing health services and actions due to the difficulty, for example, of paying for transportation to travel to health units1111 Müller A. Health for All? Sexual Orientation, Gender Identity, and the Implementation of the Right to Access to Health Care in South Africa. Health Hum Rights 2016; 18(2):195-208.,2828 Rocon PC, Rodrigues A, Zamboni J, Pedrini MD. Dificuldades vividas por pessoas trans no acesso ao Sistema Único de Saúde. Cien Saude Colet 2016; 21(8):2517-2526.. In the case of trans people, in an attempt to become intelligible, the scarcity or lack of provision of specific technologies and specialized procedures in public services causes them, many times, to undergo the processes of forging their bodies in clandestine, unsafe services and end up experiencing near-death experiences constantly3737 Ferreira BO, Nascimento EF, Pedrosa JIS, Monte LMI. Vivências de travestis no acesso ao SUS. Physis 2017; 27(4):1023-1038.

Final considerations

The instituting imaginary of society is not a mere mental image of something. It is an unceasing “social-historical and psychic” creation of ways of relating, acting, and thinking that produce realities and rationalities77 Castoriadis C. A instituição imaginária da sociedade. Rio de Janeiro: Paz e Terra; 1982.. National and international literature shows us how the imaginary that created heteronormativity has permeated, especially, practices in health services – whether in waiting rooms or inside offices – and affected the conditions of access and quality of health care for LGBTT populations. People whose gender identity and sexual orientation are different from what sexual binarism proposes are subject to prejudice, violence, and discrimination, which, added to class, skin color/ethnicity and origin markers, generate a context of vulnerabilities in the health field.

Advances in human rights laws, norms, policies, and programs, and especially concerning the health of LGBTT people, are recognized. However, besides these essential regulatory frameworks, there is a need to think about strategies for transforming practices and face-to-face interactions that occur in the interstices and the daily lives of health services. Otherwise, there is a growing risk that LGBTT populations will be increasingly removed from these institutions. Legal regulations are only realized when translated into local dynamics, that is, incorporated and shared by managers, professionals, and users of the services.

It is necessary to link, within the same principle of justice, the space for the recognition of gender injustices (social and cultural field) and the space for inequalities linked to the exploitation and redistribution of resources (economic field)5252 Fraser N. Justice Interruptus: Critical Reflections on the "Postsocialist" Condition. New York: Routledge; 1997.. This perspective imposes the reflection that the barriers faced by LGBTT populations in health services are the product of the devaluation or lack of recognition of their identities that, in a circular logic, produce or enhance restrictions regarding access to social goods and resources, including health care.

The fact of whether or not to reveal themselves to be LGBTT in interactions with health services emerged in the literature as a matter of high relevance in the health production processes of LGBTT populations. We could ask ourselves here about the “place of speech”5353 Ribeiro D. O que é lugar de fala? Belo Horizonte: Letramento; 2017. of sex-gender dissidents and the power hierarchies established in the field of health. The word “place” comes in handy. We can derive from the literature that health services have been extensions – drawers and shelves – of that invisibility and denial that has been referred to with the closet metaphor. Therefore, revealing oneself is an unavoidable part of the break with this logic. It is an operation necessary to open the “lockers”, so that LGBTT people’s rights are recognized, accessed, and realized.

Lindroth M. Competent persons who can treat you with competence, as simple as that - an interview study with transgender people on their experiences of meeting health care professionals. J Clin Nurs 2016; 25(1):3511-3521.